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The Oregon Administrative Rules contain OARs filed through March 15, 2014
 
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OREGON HEALTH AUTHORITY, OFFICE FOR OREGON HEALTH POLICY AND RESEARCH

 

 DIVISION 55

PATIENT-CENTERED PRIMARY CARE HOME PROGRAM

409-055-0000

Scope

These rules (OAR 409-055-0000 to 409-055-0090) establish the Patient-Centered Primary Care Home (PCPCH) Program and define criteria and process that the Authority shall use to recognize and verify status as PCPCHs. The PCPCH is a model of primary care that has received attention in Oregon and across the country for its potential to advance the “triple aim” goals of health reform: a healthy population, extraordinary patient care for everyone, and reasonable costs, shared by all. PCPCHs achieve these goals through a focus on wellness and prevention, coordination of care, active management and support of individuals with special health care needs, and a patient and family-centered approach to all aspects of care. PCPCHs emphasize whole-person care in order to address a patient and family’s physical and behavioral health care needs.

Stat. Auth: ORS 413.042, 414.655 & 442.210
Stats. Implemented: 413.042, 414.655 & 442.210
Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12; OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12

409-055-0010

Definitions

The following definitions apply to OAR 409-055-0000 to 409-055-0090:

(1) “Administrator” means the administrator or designee of The Office for Oregon Health Policy and Research as defined in ORS 442.011.

(2) “Authority” means the Oregon Health Authority.

(3) “CHIPRA Core Measure Set” means the initial core set of children's health care quality measures released by the Centers for Medicare and Medicaid Services in 2009 for voluntary use by Medicaid and CHIP programs.

(4) “NCQA” means National Committee for Quality Assurance.

(5) “Office” means the Office for Oregon Health Policy and Research.

(6) “Patient Centered Medical Home (PCMH)” means a practice or provider who has been recognized as such by the National Committee for Quality Assurance.

(7) “Patient-Centered Primary Care Home (PCPCH)” means a health care team or clinic as defined in ORS 414.655, meets the standards pursuant to OAR 409-055-0040, and has been recognized through the process pursuant to OAR 409-055-0040.

(8) “Personal Health Information” means demographic information, medical history, test and laboratory results, insurance information and other data that is collected by a health care professional to identify an individual and determine appropriate care.

(9) “Practice” means an individual, facility, institution, corporate entity, or other organization which provides direct health care services or items, also termed a performing provider, or bills, obligates and receives reimbursement on behalf of a performing provider of services, also termed a billing provider (BP). The term provider refers to both performing providers and BP(s) unless otherwise specified.

(10) “Program” means Patient-Centered Primary Care Home Program.

(11) “Program website” means www.primarycarehome.oregon.gov.

(12) “Provider” means an individual, facility, institution, corporate entity, or other organization which provides direct health care services or items, also termed a performing provider, or bills, obligates and receives reimbursement on behalf of a performing provider of services, also termed a billing provider (BP). The term provider refers to both performing providers and BP(s) unless otherwise specified.

(13) “Recognition” means the process through which the Authority determines if a practice has met the Oregon Patient-Centered Primary Care Home Standards.

(14) “Recognized” means that the Authority has affirmed that a practice meets the Oregon Patient-Centered Primary Care Home Standards.

(15) “Tier” means the level of Patient-Centered Primary Care Home at which the Authority has scored a practice.

(16) “Verification” means the process that Office for Oregon Health Policy and Research shall conduct to ensure that a practice has submitted accurate information to the Authority for purposes of Patient-Centered Primary Care Home recognition.

Stat. Auth: ORS 413.042, 414.655 & 442.210
Stats. Implemented: 413.042, 414.655 & 442.210
Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12; OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12

409-055-0020

Program Administration

(1) The Program is intended to ensure that there is a uniform process for recognizing PCPCHs throughout the State of Oregon in order to support primary care transformation.

(2) The Authority shall recognize practices as PCPCHs upon meeting defined criteria through the Program.

(3) The Authority shall administer the Program, including data collection and analysis, recognition, and verification that a practice meets the defined PCPCH criteria. The Authority may also provide technical assistance as is feasible.

(4) The Authority may contract for any of the work it deems necessary for efficient and effective administration of the Program.

Stat. Auth: ORS 413.042, 414.655 & 442.210
Stats. Implemented: 413.042, 414.655 & 442.210
Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12; OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12

409-055-0030

Practice Application and Recognition Process

(1) Practices, or other entities on behalf of the practice, that wish to be recognized as a PCPCH shall submit a PCPCH Recognition Application electronically to the Authority via the Program’s online application system found on the Program website or by mail to the address posted on the Program website. The application shall include the quantitative data described in OAR 409-055-0040.

(2) The Authority shall review the application within 60 days of its submission to determine whether it is accurate, complete, and meets the recognition requirements. If the application is incomplete the applicant will be notified in writing of the information that is missing and when it must be submitted.

(3) The Authority shall review a complete application within 60 days of submission. If the Authority determines that the applicant has met the requirements of these rules the Authority shall:

(a) Inform the applicant in writing that the application has been approved as a recognized PCPCH,

(b) Assign a Tier level, and

(c) Include the effective recognition date.

(4) The Authority shall maintain instructions and criteria for submitting a PCPCH Recognition Application posted on the Program website.

(5) The Authority may deny PCPCH recognition if an applicant does not meet the requirements of these rules.

(6) A Practice may request that the Authority reconsider the denial of PCPCH recognition or reconsider the assigned tier level. A request for reconsideration must be submitted in writing to the Authority within 90 days of the date of the denial or approval letter and must include a detailed explanation of why the practice believes the Authority’s decision is in error along with any supporting documentation. The Authority shall inform the practice in writing whether it has reconsidered its decision.

(7) Practices submitting applications on or after September 3, 2013 must apply to renew their recognition once every two years. Recognition will expire two years from the effective date of recognition that was issued by the Authority.

(a) At the Authority’s discretion a 30-day grace period may be allowed for PCPCHs to submit their renewal application without having a lapse in recognition status.

(b) If a PCPCH believes that it meets the criteria to be recognized at a higher tier or increase it’s point threshold by at least 15 points, it may request to have its tier status reassessed by re-submitting an application not more than once every six months. The Authority may grant exceptions to the six month time period for good cause shown.

(c) Currently recognized PCPCHs that are due to reapply between September 3, 2013 and December 31, 2013 will be granted a grace period and have the option to wait to submit a renewal application between January 1, 2014 to January 30, 2014 without having a lapse in recognition status.

Stat. Auth: ORS 413.042, 414.655 & 442.210
Stats. Implemented: 413.042, 414.655 & 442.210
Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12; OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12; OHP 7-2012(Temp), f. & cert. ef. 10-4-12 thru 4-1-13; OHP 5-2013, f. 3-22-13, cert. ef. 4-1-13; OHP 6-2013, f. 8-23-13, cert. ef. 9-3-13; OHP 9-2013, f. 10-1-13, cert. ef. 1-1-14

409-055-0040

Recognition Criteria

(1) The PCPCH recognition criteria are divided into “Must-Pass” measures and other measures that place the practice on a scale of maturity or ‘tier’ that reflect basic to more advanced PCPCH functions.

(2) Must-Pass and 5 point measures focus on foundational PCPCH elements that should be achievable by most practices in Oregon with significant effort, but without significant financial outlay.

(3) 10 and 15 point measures reflect intermediate and advanced functions.

(4) Except for the 10 Must-Pass measures, each measure is assigned a point value. A practice must meet the following point allocation criteria to be recognized as a PCPCH:

(a) Tier 1: 30–60 points and all 10 Must-Pass Measures

(b) Tier 2: 65–125 points and all 10 Must-Pass Measures

(c) Tier 3: 130 points or more and all 10 Must-Pass Measures

(5) The Authority shall calculate a practice’s point score through the recognition process described in OAR 409-055-0030.

(6) Table 1, incorporated by reference, contains the detailed list of Measures and corresponding point assignments.

(7) Table 2, incorporated by reference, contains a detailed list of the PCPCH Quality Measures.

(8) Measure specifications, thresholds for demonstrating improvement, and benchmarks for quantitative data elements are available on the Program website.

(9) National Committee for Quality Assurance (NCQA) recognition shall be acknowledged in the Authority’s PCPCH recognition process; however, a practice is not required to use its NCQA recognition to meet the Oregon PCPCH standards. A practice that does not wish to use its NCQA recognition to meet the Oregon PCPCH standards must indicate so during the PCPCH application process and submit a complete PCPCH application.

(10) A practice seeking Oregon PCPCH recognition based on its NCQA recognition must:

(a) Submit a PCPCH application and evidence of its NCQA recognition along with its application;

(b) Comply with Table 3, incorporated by reference, for NCQA PCMH practices using 2008 NCQA criteria; or

(c) Comply with Table 4, incorporated by reference, for NCQA PCMH practices using 2011 NCQA criteria.

(11) The Authority may designate a practice as a Tier 3 “Star” Patient-Centered Primary Care Home for those practices attesting to a large number of advanced PCPCH criteria. The Authority will determine the criteria for this designation no later than June 2014.

[ED. NOTE: Tables referenced are not included in rule text. Click here for PDF copy of table(s).]

Stat. Auth: ORS 413.042, 414.655 & 442.210
Stats. Implemented: 413.042, 414.655 & 442.210
Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12; OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12; OHP 9-2013, f. 10-1-13, cert. ef. 1-1-14

409-055-0050

Data Reporting Requirements for Recognized PCPCHs

(1) To be recognized as a PCPCH, a practice must attest to meeting the criteria and submit quantitative data elements to support its attestation in accordance with Tables 1 & 2, incorporated by reference.

(2) Quantitative data shall be aggregated at the practice level, not the individual patient level, and a practice may not transfer any personal health information to the Authority during the PCPCH application process.

(3) PCPCHs must submit new quantitative and attestation data as a part of the recognition renewal process and must use the specifications found on the Program website for calculating application data.

(4) If approved by the practice, other entities may submit information on behalf of a practice, as long as appropriate practice staff has reviewed all application information and data prior to submission.

(5) A practice may request an exception to any of the quantitative data reporting requirements in Table 2 or the Must-Pass criteria by submitting a form prescribed by the program. The Authority may grant exceptions for good cause shown.

(6) Practices are required to submit 12 months of quantitative data in order to meet standards 2.A., 4.A. and 4.B. A practice may request an exception to the 12 month data reporting period by submitting a form prescribed by the program. The Authority may grant exceptions for good cause shown.

(7) The Authority shall notify the practice within 60 days of complete application and exception submission whether or not the requested exception has been granted.

[ED. NOTE: Tables referenced are not included in rule text. Click here for PDF copy of table(s).]

Stat. Auth: ORS 413.042, 414.655 & 442.210
Stats. Implemented: 413.042, 414.655 & 442.210
Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12; OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12; OHP 9-2013, f. 10-1-13, cert. ef. 1-1-14

409-055-0060

Verification

(1) The Authority shall conduct at least one on-site verification review of each recognized PCPCH to determine compliance with PCPCH criteria every five years and at such other times as the Authority deems necessary or at the request of the Division of Medical Assistance Programs (DMAP), or any other applicable program within the Authority. The purpose of the review is to verify reported attestation and quantitative data elements for the purposes of confirming recognition and Tier level.

(2) PCPCHs selected for verification shall be notified no less than 30 days prior to the scheduled review.

(3) PCPCHs shall permit Authority staff access to the practice’s place of business during the review.

(4) A verification review may include but is not limited to:

(a) Review of documents and records.

(b) Review of patient medical records.

(c) Review of electronic medical record systems, electronic health record systems, and practice management systems.

(d) Review of data reports from electronic systems or other patient registry and tracking systems.

(e) Interviews with practice management, clinical and administrative staff.

(f) On-site observation of practice staff.

(g) On-site observation of patient environment and physical environment.

(5) Following a review, Authority staff may conduct an exit conference with the PCPCH representative(s). During the exit conference Authority staff shall:

(a) Inform the PCPCH representative of the preliminary findings of the review; and

(b) Give the PCPCH a reasonable opportunity to submit additional facts or other information to the Authority staff in response to those findings.

(6) Following the review, Authority staff shall prepare and provide the PCPCH specific and timely written notice of the findings.

(7) If the findings result in a referral to DMAP per OAR 409-055-0070, Authority staff shall submit the applicable information to DMAP for its review and determination of appropriate action.

(8) If no deficiencies are found during a review, the Authority shall issue written findings to the PCPCH indicating that fact.

(9) If deficiencies are found, the Authority shall take informal or formal enforcement action in compliance with OAR 409-055-0070.

(10) The Authority may share application information and content submitted by practices and/or verification findings with managed or coordinated care plans, and/or insurance carriers.

Stat. Auth: ORS 413.042, 414.655 & 442.210
Stats. Implemented: 413.042, 414.655 & 442.210
Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12; OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12; OHP 9-2013, f. 10-1-13, cert. ef. 1-1-14

409-055-0070

Compliance

(1) If the Authority finds that the practice is not in compliance with processes as attested to, the Authority shall issue a written warning requiring the practice to submit an improvement plan to the Program within 90 days of the date of the written warning. The improvement plan must include a description of the practice’s plan and timeline to correct the deficiency and proposed documentation or other demonstration that would verify the practice is in compliance.

(2) Authority will review the improvement plan and any documentation the practice submits in accordance with the deficiency, and if remedied, no further action will be taken.

(3) If a practice fails to submit the improvement plan or move into compliance within 90 days of the date of the written warning, the Authority may issue a letter of non-compliance and amend the practice’s PCPCH recognition to reflect the appropriate Tier level or revoke its PCPCH status.

(4) If the Authority amends a practice’s tier level or revokes PCPCH status this information will be made available to DMAP, the coordinated care or managed care plans, and insurance carriers.

(5) A practice that has had its PCPCH status revoked may have it reissued after reapplying for recognition and when the Authority determines that compliance with PCPCH Standards has been achieved satisfactorily.

(6) In order for the Authority to receive federal funding for Medicaid clients receiving services through a PCPCH, documentation of certain processes are required by the Centers for Medicare and Medicaid Services. Documentation requirements can be found in OAR 410-141-0860. If non-compliance is due to lack of service documentation required per OAR 410-141-0860, a referral may be made to the DMAP.

(7) If the Authority finds a lack of documentation per OAR 410-141-0860 to support the authorized tier level, the Authority may make a referral to the DMAP and may conduct an audit pursuant to the standards in OAR 943-120-1505.

Stat. Auth: ORS 413.042, 414.655 & 442.210
Stats. Implemented: 413.042, 414.655 & 442.210
Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12; OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12; OHP 9-2013, f. 10-1-13, cert. ef. 1-1-14

409-055-0080

Insurance Carrier, Managed Care Plan, and Public Stakeholder Communication

(1) The Authority shall develop a system for making recognized PCPCH Tier status recognition information available to insurance carriers and managed care organizations.

(2) The Authority shall maintain and update monthly the recognized PCPCH Tier status lists.

(3) The Authority shall develop a system for making recognized PCPCH practice names available to the general public through the Program website.

(4) Practices who do not wish to have their name listed on the publicly available list should send an e-mail to PCPCH@state.or.us with the title “opt-out” in the subject line within 10 business days of receiving confirmation of Tier status per OAR 409-055-0040.

Stat. Auth: ORS 413.042, 414.655 & 442.210
Stats. Implemented: 413.042, 414.655 & 442.210
Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12; OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12

409-055-0090

Reimbursement Objectives

(1) One objective of these standards is to facilitate appropriate reimbursement for PCPCHs consistent with their recognized Tier levels. The standards and Tier recognition process established in this rule are consistent with statutory objectives to align financial incentives to support utilization of PCPCHs, in recognition of the standards that are required to be met at different Tiers.

(2) Managed care plans and insurance carriers may obtain from the Authority the Tier level recognition of any practice.

(3) Within applicable programs, the Authority shall develop and implement reimbursement methodologies that reimburse practices based on recognition of Tier level, taking into consideration incurred practice costs for meeting the Tier criteria.

Stat. Auth: ORS 413.042, 414.655 & 442.210
Stats. Implemented: 413.042, 414.655 & 442.210
Hist.: OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12

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